What additional antihypertensive medications can be added to a regimen of Hydralazine, Lisinopril (Angiotensin-Converting Enzyme Inhibitor - ACEI) and Atenolol (Beta Blocker - BB)?

From the Guidelines

When considering additional blood pressure medications to complement hydralazine, lisinopril, and atenolol, spironolactone (25-100mg daily) would be an appropriate next option, as it is a preferred agent in resistant hypertension and can be used in conjunction with the existing medications. This is based on the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Considerations

• Spironolactone is an aldosterone antagonist that can help reduce blood pressure by increasing sodium and water excretion, and can be used in patients with resistant hypertension.
• The usual dose of spironolactone is 25-100mg daily, and it is recommended to avoid use with potassium supplements, other potassium-sparing diuretics, or significant renal dysfunction.
• It is essential to monitor for electrolyte imbalances, particularly hyperkalemia, when using spironolactone, especially in patients with chronic kidney disease or those taking other medications that can increase potassium levels.
• Regular monitoring of blood pressure and kidney function is crucial when using multiple antihypertensive medications, including spironolactone.

Alternative Options

• If spironolactone is not suitable, other options such as eplerenone (50-100mg daily) or other diuretics like chlorthalidone or hydrochlorothiazide could be considered, as they can provide additional blood pressure lowering effects.
• However, the choice of medication should be individualized based on the patient's specific needs, medical history, and potential drug interactions.

Monitoring and Follow-up

• Regular follow-up appointments are necessary to monitor the patient's response to the new medication, adjust the dose as needed, and minimize potential side effects.
• Blood pressure and kidney function should be monitored regularly, and electrolyte levels should be checked periodically to minimize the risk of complications.

From the Research

Blood Pressure Medications

To add to hydralazine, lisinopril, and atenolol, the following options can be considered:

• Labetalol: A study published in 2018 2 found that as-needed oral hydralazine and labetalol were effective in treating acute hypertension in hospitalized patients.
• Amlodipine: Research from 2019 3 showed that combinations of antihypertensive therapy, including lisinopril, losartan, or valsartan with or without hydrochlorothiazide, and amlodipine, were effective in reducing blood pressure and arterial stiffness.
• Hydrochlorothiazide: The same study from 2019 3 found that combinations of lisinopril, losartan, or valsartan with hydrochlorothiazide were effective in reducing blood pressure and arterial stiffness.
• Losartan or valsartan: These medications were also found to be effective in combination with hydrochlorothiazide and amlodipine in reducing blood pressure and arterial stiffness 3.
• Chlorthalidone: A study from 2019 4 found that chlorthalidone was associated with a lower risk of falls compared to amlodipine.

Considerations

When adding new medications to hydralazine, lisinopril, and atenolol, it is essential to consider the potential risks and benefits, including:

• The risk of falls, syncope, and orthostatic hypotension, particularly in older adults 4
• The potential for adverse interactions between medications
• The need for regular monitoring of blood pressure and adjustment of medication regimens as needed 2, 3